Your Dental Benefits – What You Should Know
Dental benefit plans are designed to share the cost of dental care. These dental benefit plans are not really insurance in the traditional sense, but are designed to provide you with assistance in paying for your dental care. A plan may have limitations on the number of office visits, consultations, cleanings, radiographs (X-rays), and various treatments it will cover. Here are some commonly misunderstood dental plan terms and features.
Your dental benefits plan purchaser (for example, your employer) makes the final decision on “maximum levels” of reimbursement through its contract with the insurance company. The annual maximum is often based on the amount the employer wishes to pay for the dental benefit. Even though the cost of dental care has increased over the years, the maximum levels of reimbursement have not changed much in 30 years.
Usual, Customary and Reasonable
“Usual, customary, and reasonable” (UCR) may be one of the most misunderstood terms used in describing dental benefit plans. UCR plans may pay an established percentage of the dentist’s fee, or what the plan considers a “customary” or “reasonable” fee limit, whichever is less.
Although these limits are called “customary,” they may or may not reflect the actual fees that dentists in your area charge. Your explanation of benefits (EOB) may note that the fee your dentist has charged you is higher than the UCR reimbursement levels the plan offers. This does not mean you have been overcharged. For example, the benefits company may not have taken into account up-to-date data in determining a reimbursement level. Keep in mind that there is no regulation as to how insurance companies determine reimbursement levels, and companies are not required to disclose how they determine these levels. This results in wide fluctuations.
Least Expensive Alternative Treatment Provisions
Your dental plan may not allow benefits for all treatment options, even when your dentist determines a specific treatment is in your best interest. For example, your dentist may recommend a dental implant, but your plan may offer reimbursement only for a removable partial denture. As with other choices in life, such as purchasing medical or automobile insurance or buying a home, the least expensive alternative is not always the best option. We will discuss all appropriate treatment options specific to your dental situation.
Questions? Ask Your Plan Sponsor
Our administrative staff cannot always answer specific questions about your dental benefits or predict the level of coverage for a particular procedure. Plans written by the same benefits company or offered by the same employer may vary according to the contracts involved. Your plan sponsor (often your employer) is usually in the best position to explain the individual design features of your plan and answer specific questions about coverage.